A 91-year-old male was seen on the surgical assessment unit due to an episode of syncope 4 days ago. His wife had found him one minute later.
This Patient had also suffered from a very general and faint intermittent abdominal pain for 7 days.
Since his fall, this abdominal pain had become more severe (9/10) and could now be localised periumbilically and radiated down suprapubically and occasionally to his back.
The past medical history was vast.
- There was an epileptic seizure 20 years ago, since when Lamotrigine has been taken. There have been no further seizures/falls since, until 2 years ago when the patient tripped over his carpet.
- HTN
- Atrial fibrillation
- Psoriasis
- Lower back and bilateral leg pain
- Repaired anal fistula
- Benign prostatic hyperplasia
- CKD
Drug History (as far as I picked up):
- Lamotrigine
- Tamsulosin
- Aspirin
- Bisoprolol
- Amlodipine
- Statin
Social history:
- Ex-smoker. 10/day for 20 years
- Drinks wine everyday
- Lives with wife
An examination was not performed because of the frailty of the patient.
What makes this case worth sharing?
At some point in this patient’s current stay at the hospital he had been diagnosed with having an Abdominal Aortic Aneurysm (AAA).
The usual management of an AAA depends on the size of the AAA:
- Small AAA (3-4.4cm): Lifestyle changes. Ultrasound scans recommended every year to see if it gets bigger.
- Medium AAA (4.5-5.4cm): Lifestyle changes. US scans every 3 months
- Large AAA (>5.5cm): surgery
This patient had a large aneurysm.
Unfortunately, he was too old and weak to undergo surgery.
He is at end of life care.
I saw his wife later that morning and first I was unsure as to whether she realises the seriousness of the situation - she mentioned how she could come back the next day if the hospital was too busy. The patient himself said that he would be perfectly fine.
It is difficult for people to accept that they might day. I’m sure the surgeon had explained the situation clearly to them.
People cope in different ways. Some cry. Some try and tackle the problem head on, with optimism. Others may live in denial.
At the very least, the patient was optimistic. There’s a fine line between denial and optimism in end of life care.
I believe that whichever method helps you cope is the best method for you (so long as you make arrangements for family members if the worst case happens).
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Written by: Jamil Shah Foridi
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